States are at the center of decisions on how to implement the coverage expansion initiatives of the Affordable Care Act. Some embraced the extension of Medicaid eligibility and built their own health insurance exchanges. Others have rejected the opportunity to bring coverage to low-income households and billions of federal dollars to their safety net providers. And while many credit or blame the ACA for the growth of high deductible health plans or for the growing use of limited provider networks, it seems clear that these are trends that were in progress for many years already.Our annual market reports and data are an invaluable source of insight into twelve state health care markets. We assemble data on health plans and provider systems and weave that analysis together with the perspectives of leaders in each market. By touring our web site, you can download samples of what is in those reports and data sets.Through our consulting research, we apply our analysis of local markets to help pharmaceutical companies, health plans, provider organizations, health purchasers, investment firms and government agencies to address the business competition and strategy issues that they face.

Competitive pressures plus changes in Medicare payment are driving more consolidation for both hospitals and health plans. In Detroit, the Beaumont, Oakwood and Botsford systems closed on their merger in 2014 and began the hard work of blending three large organizations, their cultures and information systems. The results have included much improved profitability. The entry of two for-profit companies, Vanguard Health, now part of Tenet, and Prime Healthcare in the Detroit market has resulted in more vigorous competition for a shrinking pie of hospital care. See my data and comments in HealthLeaders and in the Detroit News. Vanguard's experience with Medicare ACOs and operating HMOs may have made it a more attractive acquisition to Tenet Health, although Tenet now plans to withdraw from the health plan business and has already sold its Detroit HMO..

Some systems are pursuing other strategies for extending their geographic reach, in some cases going beyond traditional local market boundaries. In June, the Robert Wood Johnson Foundation released my report analyzing the new generation of provider-sponsored health plans. A follow-up blog posting in Health Affairs focuses on the joint venture strategy used by most of the recent health plan start-ups. RWJF also supported a 2015 study of hospital consolidation and strategic partnerships for provider systems in New Jersey. My New Jersey report describes how MD Anderson Cancer Center is taking these national networks to a new, higher level by opening an M.D. Anderson satellite at Cooper University Medical Center in Camden, NJ and its fourth center at Baptist Hospital in Jacksonville, FL. Memorial Sloan Kettering is also building a network of cancer centers, most recently in Miami, in partnership with the Baptist Health system there.

​​​​​​New coverage options through state exchanges are transforming the individual insurance markets in different states, as new competitors arrives and insurers compete on price and networks. In Florida, for example, enrollment in HMO individual plans grew by 900,000 in 18 months. Uncertainty about subsidies for consumer cost-sharing has led some insurers to drop out or to propose large rate increases for 2018.

Medicaid is now the largest line of business for HMOs in many states and they enjoyed significant, profitable growth in states that expanded eligibility under the ACA. ​Recent competitive bid processes in Michigan and Minnesota almost completely shut out major contractors UCare and HAP Midwest Health Plan, but one of the successful bidders in Minnesota dropped its contract in the face of large losses.

Strong profits but risks for hospitals with their ambitious construction projects, seeking to expand their market share and extend their geographic reach.Lauren Silverman's report for NPR describes how billions are being spent on hospital construction in north Texas and quotes me: "If I were a contractor, I would wake up every morning and thank G-d for the health care business." Peter Frost's article in the Chicago Tribune quotes me on who bears the cost for the billions in new hospital construction underway in that region. Even as more people gain individual and Medicaid coverage, inpatient admissions are flat or falling in some states. See my take in dBusiness on the impact of more than a billion dollars in new construction by Tenet and the other Detroit systems, even as the market for hospital services there is shrinking.

f you missed one of the 2015 or 2016 reports, you can order two years of reports for the discounted price of $225. Click here to order

"Analysis of Integrated Delivery Systems and Provider-Sponsored Health Plans" published by the Robert Wood Johnson Foundation, June 2017. "Thirty-seven provider-sponsored health plans have formed since 2010 and only four were profitable in 2015." Click here for a summary and to download the report and special data sets on more than 100 provider-sponsored health plans, old and new.

Recent Presentations:I spoke Friday, January 20, to the monthly breakfast meeting of the Minnesota State Bar Association Health Law Section, hosted at the Mitchell Hamline School of Law Health Institute in St Paul. The topic: "Trends and Strategies for Minnesota Health Plans and Providers." Click here to view the presentation slides

I presented on July 28, 2017 to the Minnesota Medical Group Management Association Summer Conference in Breezy Point. Click here to view the presentation slides

September 13, 2017: Presented for Minnesota Community Measurement Annual Seminar. Click here for information on MNCM. Click here to view the presentation slides

David Montgomery wrote about the 2015 report in the St. Paul Pioneer Press: "Metro hospital profits fell in 2014, while outstate earnings rose"

Dan Diamond wrote about the 2015 report in Poiltico Pulse: "The Mayo Clinic had a nearly 18 percent profit margin"

Texas Health Market Review 2016 released December 8: "Texas HMOs add 1 million Medicaid and individual members from 2013 to 2015; Hospitals are strongly profitable but inpatient use is flat; Hospitals pursue strategies of expansion and partnership."

"Recent Changes in Primary Care Delivery and Health Provider Systems in New Jersey" published by the Robert Wood Johnson Foundation, June 2015. "The trend toward consolidation of providers is likely to continue and the importance of the strategic alliances is likely to grow." Click here for a summary and to download the report and special data sets on hospitals and convenient care clinics in the state. Local coverage:

Andrew @Kitchenman wrote in NJSpotlight: "Larger Hospital Systems Loom in New Jersey's Future, New Report Forecasts" - with interactive maps and data sets

Collen O'Dea wrote in NJSpotlight: "Mapping the Location of New Jersey's Urgent Care and Retail Clinics" - with interactive maps and data sets

Lisa Ward wrote in Crain's New York Business: "New York hospitals cast an acquisitive eye toward New Jersey; Wave of mergers shifts market across the Hudson."

"The Big Picture V: New York's Private and Public Insurance Markets, 2012", released May 7, 2014. "Insurance plans specializing in public programs were fastest growing." See the summary here and download the PDF here.

Reports and data sets now available for these states:

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